OUT-OF-COUNTRY CLAIM
(to be filled out by the beneficiary)
IMPORTANT
• Please read the instructions in Section D before completing
this form
• Attach all original receipts or bills to this form – include itemized
statement (receipts not in English must be translated before
being submitted)
• Claims must be received within 90 days of the date of service
Return to: Medical Services Plan, Out-of-Country Claims
PO Box 9480 Stn Prov Govt, Victoria BC V8W 9E7
• If you leave Canada specifically to obtain medical care,
you must receive prior approval for payment of insured services
– see Section D, Elective Services on page 4
• This form must be completed and signed by the patient or their
legal guardian
• Retain copies of bills or receipts for your records
SECTION A – PATIENT INFORMATION
PATIENT LAST NAME
PATIENT FIRST NAME(S)
BIRTHDATE (DD / MM / YYYY)
GENDER
PERSONAL HEALTH NUMBER (PHN)
HOME PHONE NUMBER
MALE
WORK PHONE NUMBER
FEMALE
MAILING ADDRESS
CITY / TOWN
PROVINCE
POSTAL CODE
RESIDENTIAL ADDRESS (IF DIFFERENT FROM ABOVE)
CITY / TOWN
PROVINCE
POSTAL CODE
HAS PATIENT LIVED AT ABOVE ADDRESS FOR THE 6 MONTHS PRECEDING DEPARTURE FROM BC?
YES
NO
IF NO, PROVIDE BELOW THE RESIDENTIAL ADDRESS(ES) WHERE PATIENT WAS LIVING
PREVIOUS RESIDENTIAL ADDRESS 1
CITY / TOWN
PROVINCE
POSTAL CODE
FROM (MM / YYYY)
TO (MM / YYYY)
PREVIOUS RESIDENTIAL ADDRESS 2
CITY / TOWN
PROVINCE
POSTAL CODE
FROM (MM / YYYY)
TO (MM / YYYY)
EMPLOYER OF
NAME AND ADDRESS OF PRESENT OR LAST EMPLOYER IN BRITISH COLUMBIA
PATIENT
HEAD OF FAMILY
MONTH
DAY
NAME AND ADDRESS OF A PERSON (NOT A RELATIVE) WHO CAN CONFIRM PATIENT’S RESIDENCE IN BRITISH COLUMBIA (INCLUDE POSTAL CODE)
REASON FOR ABSENCE FROM BRITISH COLUMBIA
VACATION
STUDENT
MOVED
BUSINESS TRIP
OBTAIN MEDICAL CARE
OTHER (SPECIFY):
DO YOU HAVE EXTENDED
HEALTH BENEFITS INSURANCE
OR TRAVEL INSURANCE?
DATE OF RETURN TO BC
IF YES, NAME OF COMPANY
YES
YEAR
DATE OF DEPARTURE FROM BC
POLICY NUMBER
NO
ARE YOU OR ANY DEPENDENTS COVERED BY HEALTH INSURANCE IN ANOTHER COUNTRY?
YES
NO
If yes, attach statement of payment of claims
RELEASE OF INFORMATION
I, the patient named above, hereby authorize Out-of-Country Claims, Medical Services Plan, to obtain information necessary for the
processing of my claim from the Hospital and/or Doctor who provided care or in the event of an appeal on this case to provide the appeal
board with the appropriate information in order for an informed decision to be made.
I also authorize Out-of-Country Claims, Medical Services Plan, to provide/obtain information to/from the above named travel insurance or
extended health benefits company.
In addition, my signature below is my Application for Benefits under the Hospital Insurance Act of British Columbia.
I certify that I am the person entitled to receive benefits and that all statements made by me are true and correct.
If legal guardian, provide name and relationship to patient
SIGNATURE OF PATIENT / LEGAL GUARDIAN
NAME OF LEGAL GUARDIAN
CONTACT PHONE NUMBER
RELATIONSHIP TO PATIENT
DATE SIGNED
RESIDENTIAL ADDRESS
Personal information on this form is collected under the authority of the Medicare Protection Act and the Hospital Insurance Act. The information will be used to determine
residency in BC and determine eligibility for provincial health care benefits. If you have any questions about the collection of this information, contact an MSP client representative
at the address or telephone number shown in Section D of the form. Personal information is protected from unauthorized use and disclosure in accordance with the Freedom of
Information and Protection of Privacy Act and may be disclosed only as provided by that Act.
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SECTION B – TO CLAIM FOR DOCTOR’S FEE COMPLETE THIS SECTION
REASON FOR SEEKING MEDICAL ATTENTION (DIAGNOSIS)
TREATMENT / PROCEDURE
DURATION OF ANAESTHESIA
HRSMIN
OR
FROMTO
LABORATORY TESTS
AMOUNT PAID
(ENCLOSE PROOF OF PAYMENT)
SPECIFY EACH AREA X-RAYED
AMOUNT PAID
(ENCLOSE PROOF OF PAYMENT)
$
$
PHYSICIAN INFORMATION (if more than 7 physicians, attach additional page)
DOCTOR’S NAME AND SPECIALTY
**AMOUNT PAID – ENCLOSE PROOF OF PAYMENT
COUNTRY AND CURRENCY
HAVE YOU PAID THE ACCOUNT?
YES
1
YES
NO
MONTH
DATE
OF VISIT:
DAY
YEAR
TYPE OF VISIT
OFFICE
AMOUNT PAID**
TIME OF VISIT
HOME
HOSPITAL
DOCTOR’S NAME AND SPECIALTY
8 AM - 6 PM
6 PM - 11 PM
11 PM - 8 AM
COUNTRY AND CURRENCY
$
HAVE YOU PAID THE ACCOUNT?
YES
2
YES
NO
MONTH
DAY
YEAR
TYPE OF VISIT
OFFICE
AMOUNT PAID**
TIME OF VISIT
HOME
HOSPITAL
DOCTOR’S NAME AND SPECIALTY
8 AM - 6 PM
6 PM - 11 PM
11 PM - 8 AM
COUNTRY AND CURRENCY
$
HAVE YOU PAID THE ACCOUNT?
YES
YES
NO
MONTH
DAY
YEAR
TYPE OF VISIT
OFFICE
AMOUNT PAID**
TIME OF VISIT
HOME
HOSPITAL
DOCTOR’S NAME AND SPECIALTY
8 AM - 6 PM
6 PM - 11 PM
11 PM - 8 AM
COUNTRY AND CURRENCY
$
HAVE YOU PAID THE ACCOUNT?
YES
YES
NO
MONTH
DAY
YEAR
TYPE OF VISIT
OFFICE
TIME OF VISIT
HOME
HOSPITAL
DOCTOR’S NAME AND SPECIALTY
8 AM - 6 PM
AMOUNT PAID**
6 PM - 11 PM
11 PM - 8 AM
COUNTRY AND CURRENCY
$
HAVE YOU PAID THE ACCOUNT?
YES
YES
NO
MONTH
DAY
YEAR
TYPE OF VISIT
OFFICE
AMOUNT PAID**
TIME OF VISIT
HOME
HOSPITAL
DOCTOR’S NAME AND SPECIALTY
8 AM - 6 PM
6 PM - 11 PM
11 PM - 8 AM
COUNTRY AND CURRENCY
$
HAVE YOU PAID THE ACCOUNT?
YES
NO
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
YES
NO
MONTH
DATE
OF VISIT:
DAY
YEAR
TYPE OF VISIT
OFFICE
AMOUNT PAID**
TIME OF VISIT
HOME
HOSPITAL
DOCTOR’S NAME AND SPECIALTY
8 AM - 6 PM
6 PM - 11 PM
11 PM - 8 AM
COUNTRY AND CURRENCY
$
HAVE YOU PAID THE ACCOUNT?
YES
7
NO
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
DATE
OF VISIT:
6
NO
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
DATE
OF VISIT:
5
NO
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
DATE
OF VISIT:
4
NO
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
DATE
OF VISIT:
3
NO
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
WERE YOU REFERRED BY ANOTHER DOCTOR? IF YES, PROVIDE NAME AND ADDRESS
YES
DATE
OF VISIT:
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NO
MONTH
DAY
YEAR
TYPE OF VISIT
OFFICE
PAGE 2 OF 4
AMOUNT PAID**
TIME OF VISIT
HOME
HOSPITAL
8 AM - 6 PM
6 PM - 11 PM
11 PM - 8 AM
$
NO
SECTION C – TO CLAIM FOR IN-PATIENT HOSPITAL CHARGES COMPLETE THIS SECTION
• In-patient hospital charges include registered bed patient, dialysis, and surgical day care.
• Sections A and C must be completed in the fullest possible detail to confirm residency and entitlement for hospital benefits. See Section D
for residency requirements.
• A separate application is required for each admission to hospital.
• If the condition of the person requiring admission to hospital does not permit him/her to apply on his/her own behalf, or if he/she is an
underage dependent, this form should be completed by a member of the family or some other person having knowledge of the facts.
NAME OF HOSPITAL
MAILING ADDRESS OF HOSPITAL, INCLUDING POSTAL CODE
ADMITTING DIAGNOSIS (NATURE OF ILLNESS) AND TREATMENT PROVIDED DURING HOSPITALIZATION
DATE OF
ADMISSION:
MONTH
DAY
YEAR
DATE
OF DISCHARGE:
MONTH
DAY
YEAR
HAVE YOU PAID THE
HOSPITAL ACCOUNT?
YES
NO
AMOUNT PAID (ENCLOSE PROOF OF PAYMENT)
$
ACCIDENTAL INJURY (If hospitalization was the result of an accidental injury, complete this section)
DATE OF
ACCIDENT:
MONTH
DAY
YEAR
ACCIDENT LOCATION
TYPE OF ACCIDENT
DESCRIBE HOW THE ACCIDENT TOOK PLACE
AUTOMOBILE - (YOU WERE):
DRIVER IN TWO/MULTI-CAR COLLISION
PASSENGER IN TWO/MULTI-CAR COLLISION
PEDESTRIAN STRUCK BY AUTOMOBILE
CYCLIST STRUCK BY AUTOMOBILE
DRIVER IN AUTOMOBILE SHOW
PASSENGER IN AUTOMOBILE SHOW
OTHER TYPE OF ACCIDENT (SPECIFY):
WHO DO YOU THINK WAS RESPONSIBLE FOR THE ACCIDENT?
NAMES, ADDRESSES AND INSURANCE INFORMATION (IF KNOWN) OF OTHER DRIVERS/PERSONS INVOLVED IN ACCIDENT
FULL NAME AND ADDRESS OF OTHER DRIVER / PERSON INVOLVED IN ACCIDENT
1
NAME AND ADDRESS OF OTHER DRIVER’S / PERSON’S INSURANCE COMPANY
POLICY NUMBER
FULL NAME AND ADDRESS OF OTHER DRIVER / PERSON INVOLVED IN ACCIDENT
2
NAME AND ADDRESS OF OTHER DRIVER’S / PERSON’S INSURANCE COMPANY
POLICY NUMBER
FULL NAME AND ADDRESS OF OTHER DRIVER / PERSON INVOLVED IN ACCIDENT
3
NAME AND ADDRESS OF OTHER DRIVER’S / PERSON’S INSURANCE COMPANY
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POLICY NUMBER
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PRINT
CLEAR FORM
SECTION D - GENERAL INFORMATION
EMERGENCY OUT-OF-COUNTRY MEDICAL TREATMENT
When an eligible B.C. resident is temporarily absent from the province and must use emergency medical services in another country,
the provincial coverage is limited. For information about coverage, visit the Ministry of Health website:
http://www.health.gov.bc.ca/msp/infoben/leavingbc.html
Medical Services Plan (MSP) coverage for emergency out-of-country, physician services is limited to the B.C. physician fee rates.
Provincial coverage for emergency out-of-country, in-patient hospital services is limited to $75.00 CDN per day.
Any difference in fees will be the beneficiary’s responsibility.
If the claim indicates the out-of-country physician or hospital has not been paid, payment will be made directly to the out-of-country
physician or hospital.
If the claim is for a small amount or if the out-of-country hospital or physician will not accept payment in Canadian currency,
payment will be sent to the beneficiary and the beneficiary will be responsible to pay the account.
Please allow 12-16 weeks for processing.
ELECTIVE OUT-OF-COUNTRY MEDICAL TREATMENT
If a B.C. resident plans to leave Canada to obtain medical services in another country, provincial coverage for elective out-of-country
medical services must be approved by MSP PRIOR to leaving BC. Important coverage information and the requirement for medical
documentation is detailed on the Ministry of Health website: http://www.health.gov.bc.ca/msp/infoben/leavingbc.html#outsidecan
MSP DOES NOT PROVIDE COVERAGE FOR THE FOLLOWING:
• services that are not deemed to be medically required,
such as cosmetic surgery
• nurse anaesthetist
• dental office services
• transportation and accommodation expenses
• routine eye examinations for persons 19 to 64 years of age
• supplies and materials
• eyeglasses, hearing aids, and other equipment or appliances
• use of emergency room, private clinic/surgical facility fees
• annual or routine examinations where there is no medical need
• medical care at the request of a third party
• services of counsellors or psychologists
• medical examinations, certificates or tests required for:
°driving a motor vehicle
°immigration purposes
°employment
°school or university
°life insurance
°recreational/sporting activities
• certified physician assistant
• registered nurse/nurse practitioner
• prosthesis and appliances
• health spas and similar facilities
PROVINCIAL COVERAGE IS NOT PROVIDED OUTSIDE B.C. FOR THE FOLLOWING:
• ambulance services
• prescription drugs
• midwife services
• massage therapy
• physical therapy
• naturopathy
• chiropractic
• podiatry
• acupuncture
• optometry
• home care services
DENTAL AND ORAL SURGICAL PROCEDURES
MSP coverage for Dental and Oral surgical procedures is limited to surgery that must be performed in an acute care hospital for patient
safety and the medical complexity of the surgery. For detailed coverage information, visit the Ministry of Health website:
http://www.health.gov.bc.ca/msp/infoben/benefits.html#benefits
For more information on submitting an Out-of-Country Claim, visit the Ministry of Health website:
https://www.health.gov.bc.ca/exforms/msp/occ.html
IF YOU REQUIRE FURTHER INFORMATION, CONTACT HEALTH INSURANCE BC AT:
Health Insurance BC
Phone: 604 683-7151 (Lower Mainland)
Out-of-Country Claims
1 800 663-7100 Toll-free (Rest of BC)
PO Box 9480 Stn Prov Govt
Fax:
250 405-3588
Victoria BC V8W 9E7
Web: www.hibc.gov.bc.ca
BEFORE MAILING: Please ensure you have completed your claim form
Attach all receipts or bills to this form – include itemized statements
Ensure that you have signed all appropriate areas
HLTH 2814
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